Transitions of Care: The need for collaborationacross entire care continuum

H O T T O P I C S I N H E A L T H C A R E , I S S U E # 2

TransitionsSafe, quality

Effective

C o l l a b o r a t i v e

S u c c e s s f u l

2 Hot Top ics i n Hea l th Care : Trans i t i ons o f Care , I ssue #2

The need for collaboration across entire care continuumThis paper is the second in a series of reports on developments from The Joint Commission enterprise (TheJoint Commission, Joint Commission Resources, and the Center for Transforming Healthcare) about work underway to address the challenges related to transitions of care. The first paper in the series, “The need for amore effective approach to continuing patient care,” is available on the Transitions of Care Portal on The JointCommission website. This second paper focuses on the need for collaboration across the care continuum (asa patient moves from one care setting to another).

The Joint Commission enterprise is in the first year of a three-year initiative to define methods to achieve improvement in the effectiveness of the transitions of patients between health care organizations andprovide for the continuation of safe, quality care for patients in all settings. All three components of TheJoint Commission enterprise will offer various interventions and resources that are designed collectively to improve transitions of care. The interventions will apply to six accreditation programs: hospital, critical accesshospital, behavioral health care, home care, nursing and rehabilitation center, and ambulatory care. As part ofthis work, The Joint Commission has defined a “transition of care” as the movement of a patient from onehealth care provider or setting to another.

Developing ways to assure safe transitions of care requires collaboration among providers all along the carecontinuum. The Joint Commission recently organized a series of learning visits and focus groups to better understand the progress providers are making and the challenges they still face.

The learning visits and focus groups helped The Joint Commission to gain feedback on transitions-relatedstandards, survey processes, and tools under consideration, said Kathy Clark, M.S.N., R.N., associate projectdirector specialist in The Joint Commission’s Division of Healthcare Quality Evaluation.

Participating in the learning visits were leadership and staff from four organizations – Avera Health, EverettClinic/Providence Regional Medical Center at Everett, Marianjoy Rehabilitation Hospital and Clinics, and MDAnderson Cancer Center. Staff from The Joint Commission’s Division of Healthcare Quality Evaluation workedwith the leaders of these organizations to set the agenda for the visits, which usually lasted two to three daysand involved anywhere from 10 to 50 individuals from the host organization, depending on its size.

In addition, 90-minute focus group conference calls were held for front-line staffers from organizations participating in six of The Joint Commission’s accreditation programs: hospitals, critical access hospitals, behavioral health care, home care, nursing and rehabilitation center, and ambulatory care. The calls enabledthese workers to provide insights into the care transitions challenges they face and to share interventions contributing to successful care transitions. Discharge nurses, doctors, care coordinators, case managers, social workers, and staff from other disciplines shared their experiences transitioning patients across settings.

Hot Top ics i n Hea l th Care : Trans i t i ons o f Care , I ssue #2 3

Common approaches to making transitions successfulThe learning visits and focus groups found that health care organizations commonly address transitions at twomain points of care: at admission to the facility and then at discharge – when the patient leaves. For example,at admission, the “sender” organization contacts the next provider or “receiver” to share required informationsuch as prior medical history, current medications, and the reasons why the patient is being discharged andtransitioned to the new setting or provider.

During the learning visits, Joint Commission observers visited various health care settings associated with thefour organizations, including acute care and specialty hospitals, nursing and rehabilitation centers, behavioralhealth care clinics, home health care agencies, and ambulatory clinics. The observers found that all of the organizations were working on sender/receiver issues with partner health care organizations; these issues pertained to referrals made to the organization and to transitioning patients after discharge.

In all of these settings, there is often a screening process in place to identify patients at higher risk for healthcare problems that could possibly lead to a readmission after discharge, the observers learned. The processcommonly involves an interdisciplinary team, including a physician (or in some cases, a nurse practitioner),working together to determine what the patient will likely need after he or she leaves the setting.

Usually, case managers and/or discharge planners (who are often registered nurses or social workers) complete a formal assessment of these needs and work with physicians and other team members to plan andcoordinate the transition to the next setting. Case managers, discharge planners, and other staff then providedischarge instructions and often make follow-up appointments for patients.

The assessment identifies factors that must be addressed to assure a good outcome and prevent a readmission. Factors that may increase the risk of readmission include:

• Diagnoses associated with high readmissions

• Co-morbidities

• The need for numerous medications

• A history of readmissions

• Psychosocial and emotional factors, such as issues relating to mental health, interpersonal relationships, or

family matters

• The lack of a family member, friend or other caregiver who could provide support or assist with care

• Older age

• Financial distress

• Deficient living environment

“The literature discusses the importance of identifying patients who are at high-risk for readmission. The organizations we visited were all working on developing or improving a process to identify those high-risk patients,” said Clark.

Among the organizations participating in the learning visits, there was a consensus that these activities hadvery positive effects on transitions:

• Strong leadership support for new transitions processes

• Positive relationships between the sending and receivingproviders

• Interdisciplinary team involvement

• Handoffs that involve interpersonal communication (instead of only written or electronic communication)

• Medication reconciliation, with the involvement of pharmacists

• Two-way patient and family education – teaching the patient and family about their role and responsibility inmanaging a condition while gaining an understanding ofpsychosocial issues affecting the patient and family

• Electronic health records (EHRs), as long as they werenot relied upon as a sole method of communication. Theparticipating organizations “all had some form of bothEHRs and paper records,” Clark said.

• Assigned accountability for transitions-related tasks andoutcomes

Caring for patients receiving treatments at its Houston facilities for a wide range of cancers, MD Anderson incorporated these and other activities into the development of its primary team nursing model resulting in positive transitions. A 48-bed unit is divided into four 12-bed cohorts, with each cohort assigned a team led bya clinical nurse leader. Now implemented on four demonstration units, the model’s goal is to increase patient satisfaction scores.

Among the activities implemented within the model are interdisciplinary communication, planning for propersupport and accommodations after discharge, and advanced education aimed at the patient’s specific condition.

Debra Adornetto-Garcia, M.S.N., R.N., the executive director of MD Anderson’s Nursing Professional PracticeOffice, said the model works well because it designates responsibility and accountability for particular roles andpersons. “If you don’t name that person who’s accountable, you can struggle in an organization of our size,”she said. Another important aspect of the model is that it surrounds the accountable people with resources.“The main focus of primary team nursing is having highly effective teams,” she stated.

“

4 Hot Top ics i n Hea l th Care : Trans i t i ons o f Care , I ssue #2

““The literature discusses the

importance of identifying patients

who are at high-risk for

readmission. The organizations

we visited were all working on

developing or improving a

process to identify those

high-risk patients,” said Clark.

Hot Top ics i n Hea l th Care : Trans i t i ons o f Care , I ssue #2 5

Common challengesHealth care organizations can do a better job in contacting the receiving provider to ask what information itneeds to receive about a patient to ensure a safe transition, Clark said. “It’s important to know the organizations to which you are transitioning patients,” she emphasized. For example, Ismene Munch, Marianjoy’s director of quality, accreditation, safety and corporate compliance, said the Centers for Medicare &Medicaid Services (CMS) has strict admission and discharge requirements for rehabilitation facilities that acutecare hospitals must understand. To assist in this matter, Marianjoy has clinical liaisons on-site at sending hospitals within its west suburban Chicago service area to conduct pre-admission assessments and to assurethat Marianjoy has the appropriate equipment, staff and medications to care for the patient when he or she arrives.

Serving a population living within the intersection of South Dakota, Minnesota, Iowa and Nebraska, AveraHealth organized focus groups to learn how to better direct information to receiving facilities, said Stacy Reitmeier, M.S.W., M.B.A., the care transitions director at Avera McKennan Hospital in Sioux Falls, S.D. Averafound that a summary focusing on the patient’s immediate care needs and staffing requirements helped receiving providers to grasp the most urgent messages quickly without becoming overwhelmed with pages ofdocumentation.

The organizations that participated in the learning visits and focus groups are also taking steps to overcomeother common challenges, such as inaccurate or incomplete referral information; contradictory or confusingorder information when more than one physician is involved; primary care physicians unaware of admission ordischarge; patient illiteracy or non-compliance; transport delays; using non-clinicians to coordinate transitionsor to relay sender information; and a lack of nursing, pharmacy, or other necessary clinical staff after regularbusiness hours.

Variables of successful transitionsWhile finding agreement on “what” comprises a positive transition, the learning visits and focus groups uncovered many variables on “how” to make a successful transition from one organization to another. Thesevariables point to the need to have better tools and more in-depth standard processes. For example, the person or persons responsible for a successful transition – and when that responsibility ends – varies. Themany tasks involved in a transition – from calling the patient after discharge to the exchange of informationfrom one setting to another – are done differently from organization to organization. For example, who calls thepatient after discharge? Who does the patient call if he or she has questions? Is information between providerscommunicated by mail, phone, fax, e-mail or electronic health record? Are there sender and receiver point persons for transitions, and if so, who are they?

Clark said the process of transitioning a patient from one organization to another needs to be better addressedin all health care settings. “The current Joint Commission standards and survey process address the dischargefrom an organization, but they do not adequately address the gap between the sending and receiving careproviders,” she explained. The Joint Commission is taking an in-depth look into how health care organizationscan most effectively communicate and collaborate between the time the sender begins to prepare for discharge to when the patient arrives at the receiving care facility. “We want to bridge our organizations by better aligning their processes,” she said. Dawn Tomac, R.N., CIC, Avera’s director of quality and safety initiatives, added that acute care hospitals, nursing and rehabilitation centers, home care organizations, andother providers must “form a bigger picture together of how we all meet Joint Commission standards.”

6 Hot Top ics i n Hea l th Care : Trans i t i ons o f Care , I ssue #2

To help accomplish this goal, The Joint Commission will be looking at the tracer methodology used in its on-site survey process. Tracer methodology is an evaluation method in which surveyors select a patient, resident or client and use that individual’s record as a roadmap to move through an organization to assess andevaluate the organization’s compliance with selected standards and the organization’s systems of providingcare and services. Learning visit participants suggested taking a closer look at the screening process for discharge, education and follow-up to education (response to teaching), and discharge planning. They alsosuggested engaging the mid-level providers and case managers more in the tracers.

Measuring the effectiveness of transitionsThe primary goal of transitions of care processes is to provide the patient a safe, successful transition from oneprovider to the next. However, health care organizations are also working to improve care transitions to, in turn,reduce unnecessary readmissions. For this reason, most providers evaluate their transitions processes byevaluating their impact on readmissions data. Another common way to evaluate transitions is through patientand family satisfaction scores. Some health care organizations go beyond readmissions and satisfaction datato measure specific components of the transitions process relating to pre-admission activities, follow-up telephone calls, follow-up appointments, medication orders and management, post-discharge activities, homevisits, and more.

Avera Health’s Care Transitions program arranges for a home health nurse to visit patients within two days ofdischarge. The program also emphasizes medication management, disease-specific patient education using“teach-back” methodology, multidisciplinary intervention, and continual follow-up over a 30-day period. Focused on four major diagnoses most responsible for readmissions – congestive heart failure, acute myocardial infarction, pneumonia and chronic obstructive pulmonary disease – the program, as of Nov. 1,2012, had cared for more than 820 patients since February 2012. Preliminary data provided by Avera showedreduced readmission rates for the four major diagnoses ranging from 8.8 to 15.8 percent, across these diagnoses.

The main take-away – the need for collaborationThe need for collaboration was the most common thread through the discussions about transitions improvement. Among the many good examples of collaboration were the Everett Clinic’s partnership with theProvidence Regional Medical Center at Everett, both in Everett, Wash., as well as the work of Quality mprovement Organizations (QIOs), which provide a robust set of resources promoting seamless transitions between care settings (http://www.cfmc.org/integratingcare). QIOs are part of CMS’s Integrating Care for Populations and Communities (ICPC) initiative.

Physician-owned Everett Clinic in northwest Washington has developed systems to work smoothly with Providence Regional Medical Center and with area skilled nursing facilities and home care organizations. “You have to be able to reach out to the people you’re working with,” said Jennifer Wilson-Norton, R.Ph.,M.B.A., the clinic’s associate administrator of coordinated care. The clinic’s goal is to improve quality and decrease costs by 25 percent, primarily by preventing unnecessary hospitalizations. “There has to be ongoingcollaboration. If I’m sending you a patient, what do you need to come with that patient, and if you’re sending apatient back to me, what do I need?” she asked.

Hot Top ics i n Hea l th Care : Trans i t i ons o f Care , I ssue #2 7

Wilson-Norton said “there are tremendous opportunities to improve” cost efficiency and quality. For example,Everett started a pilot with Providence’s emergency department (ED) that offers patients who come to the EDwithout an urgent need the opportunity to see a physician at the Everett Clinic the next day. MD Anderson hasa similar program in which discharge nurses call patients who have been discharged to help with concerns andto direct them back to the clinic if necessary, said Jacqueline Anderson, MD Anderson’s director of nursing programs. Before this program was implemented, these patients often would come to the ED with questionsabout follow-up care.

Funded by CMS, 53 QIOs across the country are taking progressive steps to form community coalitions consisting of hospitals, nursing homes, patient advocacy organizations, and other stakeholders. Each QIOworks to reduce avoidable readmissions by improving processes relating to issues such as medication management, post-discharge follow-up, and care plans for patients who move across health care settings.

So far, QIOs have formed 222 coalitions or “communities” across the country, said Dr. Jane Brock, chief medical officer at the Colorado Foundation for Medical Care, the QIO for the state of Colorado. Each community is working to form cross-continuum care processes, and the work will be measured by improvements to 30-day readmission rates and overall hospital admission rates. The current QIO work is anexpansion of a concept CMS piloted during 2008-2011, when 14 QIOs worked in 14 communities to significantly reduce readmissions per 1,000 beneficiaries (compared to 50 comparison group communities).

Dr. Brock said the communities study Medicare claimsdata to understand the root causes of readmission andto assemble providers and other community stakeholders that together could impact the readmissions problem within their shared population.“We use data to understand which stakeholdersshould be part of the coalition,” she stated. The dataalso point to the need for cross-continuum teams.

With the goal of doing business a better way, “it makessense to construct more efficient and better processesacross the care continuum,” she stated. “When peoplestart to participate with their colleagues in other settings, it’s satisfying work and it makes their livesmuch easier. There’s a lot to be gained by hospitals understanding the capabilities of partners that sharetheir patient population.” Dr. Brock referenced theSTAAR (STate Action on Avoidable Rehospitalizations)Initiative and INTERACT (Interventions to ReduceAcute Care Transfers) as two outstanding resources.

“ ““When people start to

participate with their

colleagues in other settings,

it’s satisfying work and it

makes their lives much

easier. There’s a lot to be

gained by hospitals

understanding the

capabilities of partners

that share their patient

population.”

8Hot Top ics i n Hea l th Care : Trans i t i ons o f Care , I ssue #2

What makes a safe, quality transition of care?

In response to the knowledge it gains about the major facets of care transitions during its three-year initiative,The Joint Commission plans to produce a wide range of materials and products, including potential new standards and an accompanying survey process, to help Joint Commission-accredited organizations to provide safe, quality transitions of care for their patients.

Clark said scientific literature and the knowledge gained through the learning visits and focus groups makes itclear that organizations in all settings must establish seven “foundations” to assure safe transitions from onehealth care setting to another:

• Leadership support

• Multidisciplinary collaboration

• Early identification of patients/clients at risk

• Transitional planning

• Medication management

• Patient and family action/engagement

• Transfer of information

A great opportunity to share ideas and information

The organizations participating in the learning visits and focus groups appreciated the opportunity to providefeedback, and they were excited to give their staff the chance to show the progress they are making. “We were honored to be asked to participate,” said Adornetto-Garcia. “There were so many people here who wereinvolved – clinicians who have worked on our initiatives for a decade had the chance to talk about their accomplishments. . . It gave us the opportunity to acknowledge our clinicians for what they’ve done to make a difference here.”

To learn more about this topic, visit The Joint Commission’s Transitions of Care Portal.

02/13